Provider Demographics
NPI:1932428000
Name:OM FOOT AND ANKLE CORP
Entity type:Organization
Organization Name:OM FOOT AND ANKLE CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMIN
Authorized Official - Prefix:MS
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:LUGO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-932-9221
Mailing Address - Street 1:PO BOX 40055
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-1055
Mailing Address - Country:US
Mailing Address - Phone:210-932-9221
Mailing Address - Fax:210-572-9290
Practice Address - Street 1:7333 BARLITE BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78224-1320
Practice Address - Country:US
Practice Address - Phone:210-932-9221
Practice Address - Fax:210-572-9290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-27
Last Update Date:2014-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1939213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2164428-01Medicaid
TXTXB108782Medicare PIN